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I recently presented a Master’s Clinician Class at the Anxiety and Depression Association of America. My topic was cognitive conceptualization of personality disorders. I asked for a volunteer to describe a case so as a group, we could conceptualize the client, using the Cognitive Conceptualization Diagram (Beck, 2005). I have changed certain details to protect the client but his difficulties are fairly typical of someone with avoidant personality disorder.

Joe is a 52 year old man who developed PTSD 32 years before, following a series of traumatic incidents. For a long time, he lived with his family and led a fairly reclusive life. He then moved into subsidized housing which he dislikes.

Joe has been in and out of therapy for many years with many therapists. Although he no longer displays symptoms of PTSD, and hasn’t for a long time, he suffers from dysthymia. His anxiety is fairly low as he avoids situations that could lead to distress. He hasn’t had a job since he developed PTSD and has made only half-hearted attempts to secure one. He does have a few friends, “drinking buddies,” but isn’t particularly close to any of them. His relationships with his family are somewhat strained.

When the therapist listed Joe’s automatic thoughts in situations where he either felt some (mild) distress or acted in a dysfunctional way (using avoiding something), it became clear that Joe has very strong core beliefs of helplessness. Many patients have a belief in one of the three subcategories of helplessness; Joe seems to have core beliefs of being ineffective in all three.

When Joe discusses his future, he says, “My crummy apartment is preventing me from living my life.” When he considers doing his therapy homework, he thinks, “I won’t be able to do it right.” This represents the subcategory of believing one is ineffective in getting things done.

When Joe imagines going to session without having done his homework, he thinks, “She [his therapist] will be mad if I don’t do it.” When they discuss fixing up his apartment, he thinks, “I don’t want to talk about this. It will be too upsetting.” This represents the subcategory of believing one is ineffective in being able to protect oneself, in this case, in being emotionally vulnerable.

When Joe discusses his past, he thinks, “I’ve wasted so many opportunities. I’m a loser.” When Joe fails to protest a teasing insult from his buddy, he thinks, “I should have said something. I’m a wimp.” This represents the subcategory of being ineffective as compared to others.

Joe’s sense of helplessness has led to extensive behavioral avoidance. He procrastinates, avoids doing homework or cleaning up his apartment. It has led to extensive social avoidance. He avoids intimacy in relationships. And it has led to extensive cognitive and emotional avoidance. He over-intellectualizes, changes the subject in therapy, and avoids even thinking about upsetting topics. And he fails to take responsibility for improving his life, blaming his mother, PTSD, and his living situation for holding him back.

Clients’ emotional and behavioral reactions always make sense once we understand what they are thinking. And the patterns or themes in their thinking always make sense once we understand the fundamental ways they view themselves, other people, and their worlds.

Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford Press.

According to a recent study published in the Journal of Consulting and Clinical Psychology, cognitive-behavior treatments (CBT) may provide long-term improvements for PTSD and related symptoms. CBTs such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) have already been shown to be effective and are considered some of the “first line treatments” for PTSD. However, the important question of CBT’s long term efficacy for PTSD has not been explored as deeply, as follow ups typically occur only three to six months after treatment.

The current study compares the long term outcomes of CPT and PE for PTSD in female rape survivors. The original study measured symptoms of women suffering from PTSD (n=171), before and after receiving either CPT or PE. This long term follow up, from 4.5 to 10 years later (M = 6.15), includes 73.7% of the original sample following initial treatments (n= 126) of CPT (n= 63) or PE (n=63). Researchers used the PTSD Symptom Scale (PSS), the Beck Depression Inventory (BDI), and the Clinician-Administered PTSD Scale (CAPS) to measure PTSD symptoms. Of those allocated to CPT, 46 completed the therapy, 10 received some therapy, and 7 did not start. Of those allocated to PE, 44 completed the therapy, 13 received some therapy, and 6 did not start.

Participants who received both cognitive therapies (CPT and PE) showed significant improvements in PTSD and related symptoms from pre- to post-treatment. There was no marked significance in the difference between the two samples receiving treatment. During the long term follow up, there was an impressive amount of maintenance of these improvements in symptoms. At pre-treatment assessment, 100% of participants had met criteria for PTSD; however, at the long term follow up only 22.2% of participants in the CPT group and 17.5% in the PE group met criteria for PTSD. In addition, there was no further psychotherapy or medication use reported which could have otherwise accounted for the long term efficacy of these treatments.

Female rape survivors in this study benefitted significantly from a lasting improvement in PTSD symptoms. Although further research and replication studies are needed, these findings suggest that CBT may be effective for years following initial treatment.

According to a recent study published in the Journal of Psychosomatic Research, cognitive behavior therapy (CBT) may improve sleep and reduce daytime PTSD symptoms among military veterans. The current study compared Prazosin (a pharmacological treatment for sleep disturbance) versus a CBT sleep intervention against a placebo control. Fifty US military veterans were randomly assigned to either the Prazosin group (n = 18), the CBT group (n = 17), or the placebo group (n = 15). Both active groups (Prazosin and CBT) showed greater reductions in insomnia and daytime PTSD symptom severity. Overall sleep improvements were noted in 61.9% of those who completed the active treatments and 25% of those in the placebo group. These results suggest that both pharmacological and CBT interventions may improve sleep and reduce PTSD symptoms among military veterans.

According to a recent meta-analytic review published in Psychological Reports, VA-treated patients respond more positively to PTSD treatment and fare better (66% in the current review) than patients in non-VA control conditions. Twenty-four PTSD studies were selected for inclusion; each study was classified into four treatment categories: (1) exposure-based studies, (2) other cognitive behavioral studies, (3) inpatient studies, and (4) miscellaneous treatment. Of the four treatment categories, exposure-based treatment had the highest within-group effect size. These findings are encouraging for patients with PTSD who seek treatment at Veterans Affairs hospitals.

Researchers from the Engineering in Medicine and Biology Society (EMBS) are currently examining the effects of cognitive behavior therapy (CBT) delivered via mobile device to patients suffering from drug-addiction and post-traumatic stress disorder (PTSD). The delivery system involves an ankle sensor (to monitor electrodermal activity, 3-axis acceleration, and temperature) and an ECG heart monitor. The monitors contain bluetooths which are connected to patients’ cell phones. When certain arousal levels are detected via the monitoring system, therapeutic messages are delivered by text to patients’ cell phones. The effectiveness of this system is being evaluated.

A recent study published in Behavior Therapy provides initial evidence for the efficacy of manualized Cognitive Behavior Therapy (CBT) for disaster-exposed youth with posttraumatic stress disorder (PTSD). Previous research suggests that group-based CBT is effective in decreasing post-traumatic stress levels in youth. Treatment is often difficult to obtain for this population, however, due to lack of resources. The current study eliminated this obstacle by providing treatment within a school setting.

The current research was conducted on six youth exposed to Hurricane Katrina. The participants ranged from ages 8 to 13 from neighborhoods that experienced significant destruction following the disaster. Master’s level graduate students administered pre and post-tests to participants, and treatment was conducted by a doctoral level therapist using the StArT intervention— a trauma-focused CBT program designed specifically for hurricane-exposed youth. Treatment consisted of 10 sessions which included psychoeducation, cognitive restructuring, exposure, problem solving, and relapse prevention.

Following the intervention, participants showed a decline in PTSD symptoms and no longer met criteria for PTSD at post-treatment. Half of the participants reported no other anxiety disorder diagnoses following treatment, and there was an overall reduction in the incidence of other anxiety problems common in this population. While replication studies and further assessments are needed, the StArT manual shows promising potential as an effective CBT manual for disaster-exposed youth.